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On my first day of my very first placement, everything seemed unfamiliar. I couldn’t remember the names of any medications. I was slightly terrified of actually speaking to a real patient. I couldn’t even put on a blood pressure cuff properly.

This article, the second in a six-part series on communication skills, a discusses the barriers to effective communication and how to overcome them

Abstract

Competing demands, lack of privacy, and background noise are all potential barriers to effective communication between nurses and patients. Patients’ ability to communicate effectively may also be affected by their condition, medication, pain and/or anxiety. Nurses’ and patients’ cultural values and beliefs can also lead to misinterpretation or reinterpretation of key messages. This article, the second in a six-part series on communication skills, suggests practical ways of overcoming the most common barriers to communication in healthcare.

Author: Moi Ali is a communications consultant, a board member of the Scottish Ambulance Service and of the Professional Standards Authority for Health and Care, and a former vice-president of the Nursing and Midwifery Council.

Introduction

It is natural for patients to feel apprehensive about their health and wellbeing, yet a survey in 2016 found that only 38% of adult inpatients who had worries or fears could ‘definitely’ find someone in hospital to talk to about them (Care Quality Commission, 2017). There are numerous barriers to effective communication including:

Time constraints;

Environmental issues such as noise and privacy;

Pain and fatigue;

Embarrassment and anxiety;

Use of jargon;

Values and beliefs;

Information overload.

Time constraints

Time – or lack of it – creates a significant barrier to communication for nurses (Norouzinia et al, 2016). Hurried communication is never as effective as a leisurely interaction, yet in pressured workplaces, nurses faced with competing demands may neglect the quality of communication. It is important to remember that communication does not need to be time-consuming – a smile, hello, or some ‘small talk’ about the weather may suffice. Even when there is no pressing news to tell individual patients, taking the time to get to know them can prepare the ground for difficult conversations that may need to take place in the future.

In a pressured ward or clinic, conversations between patients and nurses may be delayed or interrupted because of the needs of other patients – for example, they may need to respond to an emergency or pain relief. This can be frustrating for patients who may feel neglected. If interruptions occur it is important to explain to patients that you have to leave and why. Arranging to return within a specified time frame may be enough to reassure them that you are aware that their concerns are important (Box 1).

Box 1. Making time for communication

Nurse Amy Green was allocated a bay of four patients and two side wards for her shift. Halfway through the morning one of her patients in a side ward became very ill and Amy realised that she needed to spend a lot of time with him. She quickly visited her other patients to explain what was happening, and reassured them that she had not forgotten about them. She checked that they were comfortable and not in pain, asked them to ring the call bell if they needed her, and explained that she would return as soon as she could. The patients understood the situation and were reassured that their immediate needs had been assessed and they were not being neglected.

Environmental factors

You may be so familiar with your surroundings that you no longer notice the environmental factors that can create communication difficulties. Background noise in a busy clinic can affect patients’ ability to hear, and some may try to disguise this by nodding and ‘appearing’ to hear. If you think your patient has hearing problems, reduce background noise, find a quiet corner or step into a quiet side room or office. Check whether your patient uses physical aids, such as hearing aids or spectacles and that these are in working order.

Noise and other distractions can impede communication with patients with dementia and other cognitive impairments, who find concentration challenging. If you have to communicate an important message to a patient with poor concentration, it is useful to plan ahead and identify the best place and time to talk. It can be helpful to choose a time when you are less busy, without competing activities such as medicine rounds or meal times to interrupt your discussion.

Patients may be reticent to provide sensitive personal information if they are asked about their clinical history within earshot of other people, such as at a busy reception desk or in a cubicle with just a curtain for privacy. It is important to avoid asking sensitive questions where others may hear patients’ replies. Consider alternative ways of gathering pertinent information, such as asking the patient to complete a written form – but remember that some patients struggle with reading and writing or may need the form to be provided in a different language or have someone translate for them.

Pain and fatigue

We often need to gain important information from patients when they are acutely ill and distressed, and symptoms such as pain can reduce concentration. If you urgently need to gather information, it is important to acknowledge pain and discomfort: “I know that it is painful, but it’s important that we discuss.”

Patients may also be tired from a sleepless night, drowsy after an anaesthetic or experiencing the side-effects of medicines. Communicating with someone who is not fully alert is difficult, so it is important to prioritise the information you need, assess whether it is necessary to speak to the patient and ask yourself:

Is this the best time for this conversation?

Can my message wait?

Can I give part of the message now and the rest later?

When patients cannot give their full attention, consider whether your message could be broken down into smaller pieces so there is less to digest in one go: “I will explain your medication now. I’ll return after lunch to tell you about how physiotherapy may help.” Ask if they would like any of the information repeated.

If you have to impart an important piece of information, acknowledge how the patient is feeling: “I know that you’re tired, but …”. Showing empathy can build rapport and make patients more receptive. It may also be useful to stress the need to pay attention: “It’s important that you listen because …”. Consider repeating the message: “It can be difficult to take everything in when you’re tired, so I just wanted to check that you’re clear about …”. If the communication is important, ask the patient to repeat it back to you to check it has been understood.

Embarrassment and anxiety

Would you feel comfortable undressing in front of a complete stranger, or talking about sex, difficult family circumstances, addictions or bowel problems? Patients’ and health professionals’ embarrassment can result in awkward encounters that may hamper effective communication. However, anticipating potential embarrassment, minimising it, and using straightforward, open communication can ease difficult conversations. For example, in a clinic, a patient may need to remove some clothes for an examination. It is important to be direct and specific. Do not say: “Please undress”, as patients may not know what to remove; give specific instructions: “Please remove your trousers and pants, but keep your shirt on”. Clear directions can ease stress and embarrassment when delivered with matter-of-fact confidence.

Patients may worry about embarrassing you or themselves by using inappropriate terms for anatomical parts or bodily functions. You can ease this embarrassment by introducing words such as “bowel movements” or “penis” into your questions, if you think they are unsure what terminology to use. Ambiguous terms such as “stool”, which have a variety of everyday meanings, should be avoided as they may cause confusion.

Many patients worry about undergoing intimate procedures such as bowel and bladder investigations. Explain in plain English what an examination involves, so that patients know what to expect. Explaining any side-effects of procedures – such as flatulence or vomiting – not only warns patients what to expect but reassures them that staff will not be offended if these occur.

Box 2 provides some useful tips on dealing with embarrassment.

Box 2. Managing embarrassment

Look out for signs of embarrassment – not just obvious ones like blushing, but also laughter, joking, fidgeting and other behaviours aimed at masking it

Think about your facial expressions when communicating with patients, and use positive, open body language such as appropriate eye contact or nodding

Avoid disapproving or judgmental statements by phrasing questions carefully: “You don’t drink more than 10 glasses of wine a week, do you?” suggests that the ‘right’ or desired answer is ‘no’. A neutral, open question will elicit a more honest response: “How many glasses of wine do you drink in a typical week?”

Some patients are reluctant to ask questions, seek clarification or request that information be repeated for fear of wasting nurses’ time. It is important to let them know that their health or welfare is an integral part of your job. They also need to know that there is no such thing as a silly question. Encourage questions by using prompts and open questions such as: “You’re bound to have questions – are there any that I can answer for you now?”; “What else can I tell you about the operation?”. It is also possible to anticipate and address likely anxieties such as “Will it be painful?”; “Will I get better?”; or “Will I die?”.

Jargon

Jargon can be an important communication aid between professionals in the same field, but it is important to avoid using technical jargon and clinical acronyms with patients. Even though they may not understand, they may not ask you for a plain English translation. It is easy to slip into jargon without realising it, so make a conscious effort to avoid it.

A report on health literacy from the Royal College of General Practitioners (2014) cited the example of a patient who took the description of a “positive cancer diagnosis” to be good news, when the reverse was the case. If you have to use jargon, explain what it means. Wherever possible, keep medical terms as simple as possible – for example, kidney, rather than renal and heart, not cardiac. The Plain English website contains examples of healthcare jargon.

Box 3 gives advice on how to avoid jargon when speaking with patients.

Box 3. Avoiding jargon

Avoid ambiguity: words with one meaning for a nurse may have another in common parlance – for example, ‘acute’ or ‘stool’

Use appropriate vocabulary for the audience and age-appropriate terms, avoiding childish or over-familiar expressions with older people

Avoid complex sentence structures, slang or speaking quickly with patients who are not fluent in English

Use easy-to-relate-to analogies when explaining things: “Your bowel is a bit like a garden hose”

Avoid statistics such as “There’s an 80% chance that …” as even simple percentages can be confusing. “Eight in every 10 people” humanises the statistic

Values, beliefs and assumptions

Everyone makes assumptions based on their social or cultural beliefs, values, traditions, biases and prejudices. A patient might genuinely believe that female staff must be junior, or that a man cannot be a midwife. Be alert to patients’ assumptions that could lead to misinterpretation, reinterpretation, or even them ignoring what you are telling them. Think about how you can address such situations; for example explain your role at the outset: “Hello, I am [your name], the nurse practitioner who will be examining you today.”

It is important to be aware of your own assumptions, prejudices and values and reflect on whether they could affect your communication with patients. A nurse might assume that a patient in a same-sex relationship will not have children, that an Asian patient will not speak good English, or that someone with a learning disability or an older person will not be in an active sexual relationship. Incorrect assumptions may cause offence. Enquiries such as asking someone’s “Christian name” may be culturally insensitive for non-Christians.

Information overload

We all struggle to absorb lots of facts in one go and when we are bombarded with statistics, information and options, it is easy to blank them out. This is particularly so for patients who are upset, distressed, anxious, tired, in shock or in pain. If you need to provide a lot of information, assess how the patient is feeling and stick to the pertinent issues. You can flag up critical information by saying: “You need to pay particular attention to this because …”.

Box 4 provides tips on avoiding information overload.

Box 4. Avoiding information overload

Consider suggesting that your patient involves a relative or friend in complex conversations – two pairs of ears are better than one. However, be aware that some patients may not wish others to know about their health

Suggest patients take notes if they wish

With patients’ consent, consider making a recording (or asking whether the patient wishes to record part of the consultation on their mobile phone) so they can replay it later or share it with a partner who could not accompany them

Give written information to supplement or reinforce the spoken word

Arrange another meeting if necessary to go over details again or to provide further information

Conclusion

It is vital that all nurses are aware of potential barriers to communication, reflect on their own skills and how their workplace environment affects their ability to communicate effectively with patients. You can use this article and the activity in Box 5 to reflect on these barriers and how to improve and refine your communication with patients.

Box 5. Reflective activity

Think about recent encounters with patients:

What communication barriers did you encounter?

Why did they occur?

How can you amend your communication style to take account of these factors so that your message is not missed, diluted or distorted?

Do you need support to make these changes?

Who can you ask for help?

Key points

Nurses need to be aware of the potential barriers to communication and adopt strategies to address them

Environmental factors such as background noise can affect patients’ ability to hear and understand what is being said to them

Acute illness, distress and pain can reduce patients’ concentration and their ability to absorb new information

Anticipating potential embarrassment and taking steps to minimise it can facilitate difficult conversations

It is important to plan ahead and identify the best place and time to have important conversations

A new documentary filmed on the paediatric intensive care unit at a children’s hospital is hoping to show the public the complex, but also caring, discussions that occur when clinicians are treating children with life-limiting conditions, according to a nurse involved in the programme.

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